COVID-19 in pregnancy: the foetal perspective-a systematic review

Vertical Transmission of SARS-CoV-2 during Pregnancy: A Prospective Italian Cohort Study

OBJECTIVE

 The extent of vertical transmission (VT) of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from mothers their fetuses or neonates is still uncertain. We aimed to determine the incidence of VT.

STUDY DESIGN

 In this prospective cohort study. All mother diagnosed with SARS-CoV-2 infection at the time of delivery or up to 1 week prior and their neonates, managed in a tertiary referral hospital for pregnancy complicated by coronavirus disease 2019 (COVID-19) in Rome, from April 2 to December 22, 2020, were included. Maternal infection was defined as nasopharyngeal swab test results positive for SARS-CoV-2 reverse transcription-polymerase chain reaction (RT-PCR). Biological samples were collected before, at, and after delivery to test positivity for SARS-CoV-2 RT-PCR and anti-SARS-CoV-2-specific antibodies.

RESULTS

 The cohort included 95 women and 96 neonates with documented SARS-CoV-2 test results. Four neonates (4.2%) tested positive. The incidence of VT, according to the guidance criteria for diagnosing perinatal SARS-CoV-2 infection, was 5.2%. Neonatal symptoms were due to prematurity or fetal distress: symptomatic infants had lower median (min-max) gestational age, 38.1 (29.3-40.6) versus 39.3 (33.9-41.9) weeks (p = 0.036), and 1-minute and 5-minute Apgar scores, 9 (3-9) versus 9 (7-10) (p = 0.036) and 10 (6-10) versus 10 (8-10) (p = 0.012), respectively, than asymptomatic infants and needed more frequent assistance in the delivery room (22.2 vs 2.5%; p = 0.008). Only six (7.1%) neonates had anti-SARS-CoV-2-specific antibodies, despite the ongoing maternal infection.

CONCLUSION

 The incidence of VT is low as is the detection of specific anti-SARS-CoV-2 antibodies in cord blood when infection is contracted late in pregnancy. This would suggest poor protection of infants against horizontal transmission of the virus.

KEY POINTS

· VT of SARS-CoV-2 from pregnant mothers to fetuses or neonates can be possible.. · In this prospective cohort study, the incidence of VT is found to be 5.2%.. · VT is low but exists..

Impact of respiratory viral infections during pregnancy on the neurological outcomes of the newborn: current knowledge

Brain development is a complex process that begins during pregnancy, and the events occurring during this sensitive period can affect the offspring's neurodevelopmental outcomes. Respiratory viral infections are frequently reported in pregnant women, and, in the last few decades, they have been related to numerous neuropsychiatric sequelae. Respiratory viruses can disrupt brain development by directly invading the fetal circulation through vertical transmission or inducing neuroinflammation through the maternal immune activation and production of inflammatory cytokines. Influenza virus gestational infection has been consistently associated with psychotic disorders, such as schizophrenia and autism spectrum disorder, while the recent pandemic raised some concerns regarding the effects of severe acute respiratory syndrome coronavirus 2 on neurodevelopmental outcomes of children born to affected mothers. In addition, emerging evidence supports the possible role of respiratory syncytial virus infection as a risk factor for adverse neuropsychiatric consequences. Understanding the mechanisms underlying developmental dysfunction allows for improving preventive strategies, early diagnosis, and prompt interventions.

Pregnancy-Related Complications During the COVID-19 Pandemic in Iran

BACKGROUND

The COVID-19 pandemic has profoundly affected healthcare systems worldwide, with significant collateral damage to vulnerable populations, including the perinatal population. This study sought to compare pregnancy-related complications before and during the COVID-19 pandemic in Iran.

METHODS

This retrospective data analysis was performed from February 20 to August 20, 2019 (prior to the onset of the COVID-19 pandemic) and from February 20 to August 20, 2020 (during the pandemic), encompassing the initial wave of the pandemic and the subsequent lockdown. To collect data, we utilized the medical records of 168,358 women obtained from the Iranian Maternal and Neonatal Network, which is a comprehensive electronic health record database management system specifically designed to store information pertaining to maternal and neonatal health.

RESULTS

A total of 168,358 medical records were analyzed, with 87388 (51.9%) and 80970 (48.1%) before and during the pandemic, respectively. The occurrence of pregnancy complications was found to be significantly more frequent during the pandemic compared to the pre-pandemic period. Notably, there was a higher likelihood of experiencing preeclampsia (odds ratio [OR]=1.14, 95% confidence interval [CI]: 1.07‒1.22, P=0.0001) and gestational diabetes (OR=1.14, 95% CI: 1.09‒1.19, P=0.0001) during the pandemic. Furthermore, cesarean section (CS) became more prevalent during the pandemic in comparison to vaginal delivery (OR=1.19, 95% CI: 1.17‒-1.22, P=0.0001).

CONCLUSION

Our findings demonstrated a significant association between the COVID-19 pandemic and an escalation in adverse pregnancy outcomes, notably preeclampsia, gestational diabetes, and CS deliveries. However, further research is warranted to gain a richer understanding of the intricate interplay between the COVID-19 pandemic and pregnancy complications. This is particularly crucial in light of the evolving landscape of new coronavirus variants.

Molecular Basis of Müllerian Agenesis Causing Congenital Uterine Factor Infertility-A Systematic Review

Infertility affects around 1 in 5 couples in the world. Congenital absence of the uterus results in absolute infertility in females. Müllerian agenesis is the nondevelopment of the uterus. Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a condition of uterovaginal agenesis in the presence of normal ovaries and the 46 XX Karyotype. With advancements in reproductive techniques, women with MA having biological offspring is possible. The exact etiology of MA is unknown, although several genes and mechanisms affect the development of Müllerian ducts. Through this systematic review of the available literature, we searched for the genetic basis of MA. The aims included identification of the genes, chromosomal locations, changes responsible for MA, and fertility options, in order to offer proper management and counseling to these women with MA. A total of 85 studies were identified through searches. Most of the studies identified multiple genes at various locations, although the commonest involved chromosomes 1, 17, and 22. There is also conflicting evidence of the involvement of various candidate genes in the studies. The etiology of MA seems to be multifactorial and complex, involving multiple genes and mechanisms including various mutations and mosaicism.

From pandemic to syndemic: microbiota, pregnancy, and environment at a crossroad

Aim: SARS-CoV2 is the latest pandemic that have plagued the socio-health system as an epiphenomenon resulting from planetary resources abuse, crucial for biodiversity. The Anthropocene best defines the present epoch in which human activity irreversibly manipulates intricate and delicate geological and biological balances established over eons. The devastating ecological and socio-economic implications of COVID-19, underline the importance of updating the present pandemic framework to a syndemic. This paper stems from the need to suggest to scientists, doctors, and patients a mission that integrates responsibility from individual to collective health, from present to trans-generational, from human to the entire biotic network. Today's choices are crucial for the perspective on all levels: political, economic, and health as well as cultural.Methods: Research on PubMed and other specific web-sites journal was performed on the topic "Microbiota", "Covid-19", "Pandemic", "Zoonosis", "SARS-CoV-2", "Environmental Pollutants", "Epigenetics", "Fetal Programming", "Human Extinction". Data collected were analysed for an integrative model of interconnection between environment, pregnancy, SARS-CoV-2 infection, and microbiota. Moreover, systematic literature review allowed to summarise in a table information about the worst pandemics that afflicted the human species recently.Results: This paper offers a broad view of the current pandemic starting with pregnancy, the moment when a new life begins and the health trajectories of the unborn child are defined, which will inevitably have repercussions on his well-being. The fundamental role of the biodiversity-rich microbiota in avoiding the development of severe infectious diseases, is therefore highlighted. It is imperative to adjust the current reductionist paradigm based on mostly immediate symptom management towards a broader understanding of the spatial interconnection of ecological niches with human health and the impacts of today's choices on the future. Health and healthcare are elitist rather than egalitarian, therefore focusing on environmental health forces us to make a concerted and systemic effort that challenges political and economic barriers, which are biologically senseless. A healthy microbiota is essential to well-being, both by preventing chronic degenerative conditions, the infectiousness and pathogenicity of bacterial and viral diseases. SARS-CoV-2 should not be an exception. The human microbiota, forged by the first 1,000 days of life, is fundamental in shaping the health-disease trajectories, and by the everlasting exposome that is dramatically affected by the ecological disaster. Individual health is one world health whereas single and global well-being are interdependent in a space-time perspective.Conclusions: Is it not a convenient reductionism not to consider the COVID-19 emergency as a bio-social epiphenomenon of a far more devastating and multi-faceted crisis whose common denominator is the global biotic network loss of which humans are still part?

Maternal immune activation and role of placenta in the prenatal programming of neurodevelopmental disorders

Maternal infection during pregnancy, leading to maternal immune activation (mIA) and cytokine release, increases the offspring risk of developing a variety of neurodevelopmental disorders (NDDs), including schizophrenia. Animal models have provided evidence to support these mechanistic links, with placental inflammatory responses and dysregulation of placental function implicated. This leads to changes in fetal brain cytokine balance and altered epigenetic regulation of key neurodevelopmental pathways. The prenatal timing of such mIA-evoked changes, and the accompanying fetal developmental responses to an altered in utero environment, will determine the scope of the impacts on neurodevelopmental processes. Such dysregulation can impart enduring neuropathological changes, which manifest subsequently in the postnatal period as altered neurodevelopmental behaviours in the offspring. Hence, elucidation of the functional changes that occur at the molecular level in the placenta is vital in improving our understanding of the mechanisms that underlie the pathogenesis of NDDs. This has notable relevance to the recent COVID-19 pandemic, where inflammatory responses in the placenta to SARS-CoV-2 infection during pregnancy and NDDs in early childhood have been reported. This review presents an integrated overview of these collective topics and describes the possible contribution of prenatal programming through placental effects as an underlying mechanism that links to NDD risk, underpinned by altered epigenetic regulation of neurodevelopmental pathways.

Multisystem inflammatory disease in neonates (MIS-N) due to maternal COVID-19

Multisystem inflammatory disease in neonates (MIS-N) is a disease of immune dysregulation presenting in the newborn period. Thouvgh its etiopathogenesis is proposed to be similar to multisystem inflammatory disease in Children (MIS-C), the exact pathophysiology is largely unknown as of present. The definition of MIS-N is contentious. The evidence for its incidence, the clinical features, profile of raised inflammatory markers, treatment strategies and outcomes stem from case reports, case series and cohort studies with small sample sizes. Though the incidence of MIS-N in severe acute respiratory syndrome caused by the coronavirus CoVID-2 (SARS-CoV-2) infected asymptomatic neonates is low, its incidence in symptomatic neonates is relatively higher. Further, amongst the neonates who are treated as MIS-N, the mortality rate is high. The review also evaluates the various other unresolved aspects of MIS-N from limited published literature and identifies knowledge gaps which could be areas of future research.

Immune Responses to SARS-CoV-2 in Pregnancy: Implications for the Health of the Next Generation

Widespread SARS-CoV-2 infection among pregnant individuals has led to a generation of fetuses exposed in utero, but the long-term impact of such exposure remains unknown. Although fetal infection is rare, children born to mothers with SARS-CoV-2 infection may be at increased risk for adverse neurodevelopmental and cardiometabolic outcomes. Fetal programming effects are likely to be mediated at least in part by maternal immune activation. In this review, we discuss recent evidence regarding the effects of prenatal SARS-CoV-2 infection on the maternal, placental, and fetal immune response, as well as the implications for the long-term health of offspring. Extrapolating from what is known about the impact of maternal immune activation in other contexts (e.g., obesity, HIV, influenza), we review the potential for neurodevelopmental and cardiometabolic morbidity in offspring. Based on available data suggesting potential increased neurodevelopmental risk, we highlight the importance of establishing large cohorts to monitor offspring born to SARS-CoV-2-positive mothers for neurodevelopmental and cardiometabolic sequelae.

COVID-19 in pregnancy: implications for fetal brain development

The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during pregnancy on the developing fetal brain is poorly understood. Other antenatal infections such as influenza have been associated with adverse neurodevelopmental outcomes in offspring. Although vertical transmission has been rarely observed in SARS-CoV-2 to date, given the potential for profound maternal immune activation (MIA), impact on the developing fetal brain is likely. Here we review evidence that SARS-CoV-2 and other viral infections during pregnancy can result in maternal, placental, and fetal immune activation, and ultimately in offspring neurodevelopmental morbidity. Finally, we highlight the need for cellular models of fetal brain development to better understand potential short- and long-term impacts of maternal SARS-CoV-2 infection on the next generation.

Doctor/Data Scientist/Artificial Intelligence Communication Model. Case Study

The last two years have taught us that we need to change the way we practice medicine. Due to the COVID-19 pandemic, obstetrics and gynecology setting has changed enormously. Monitoring pregnant women prevents deaths and complications. Doctors and computer data scientists must learn to communicate and work together to improve patients' health. In this paper we present a good practice example of a competitive/collaborative communication model for doctors, computer scientists and artificial intelligence systems, for signaling fetal congenital anomalies in the second trimester morphology scan.

The Effect of COVID-19 Infection During Pregnancy; Evaluating Neonatal Outcomes and the Impact of the B.1.1.7. Variant

BACKGROUND

Coronavirus disease 2019 (COVID-19) infection during pregnancy has been associated with adverse perinatal outcomes. We aim to evaluate the neonatal outcomes including the incidence of preterm birth, admission to the neonatal unit and incidence of congenital anomalies in this cohort. We will also describe these outcomes in the context of the B.1.1.7. variant outbreak, the dominant variant in Ireland since January 2021, which has had a greater impact on pregnant patients.

METHODS

This was a retrospective study of liveborn infants, delivered between 1st March 2020 and 1st March 2021, to women with a severe acute respiratory syndrome coronavirus 2 diagnosis during pregnancy, in a tertiary maternity hospital (8,500 deliveries/year). Clinical data were collected, and analyses were performed to evaluate the impact of maternal symptom status, time from diagnosis to delivery and the B.1.1.7. variant on neonatal outcome.

RESULTS

In total 133 infants (1.6%) were born to women with severe acute respiratory syndrome coronavirus 2 identified during pregnancy. The median birth weight was 3.45 kg and gestational age at birth was 39.3 weeks. 14 infants (10.5%) were preterm. 22 infants (16.5%) required admission to the neonatal unit and 7 (5.3%) were small for gestational age. There was no difference in growth, preterm birth or neonatal unit admission based on maternal symptom status or infection after the outbreak of B.1.1.7. as the dominant strain.

CONCLUSIONS

Following a COVID-19 infection in pregnancy, there was no increase in the incidence of preterm birth or neonatal intensive care unit admission compared with 5-year hospital data. Maternal symptom status did not influence neonatal outcomes. Further studies to evaluate the impact of COVID-19 in early pregnancy, the variants of concern, particularly the emerging Delta variant and COVID-19 placentitis are required.

Neuropathogenesis of severe acute respiratory syndrome coronavirus 2

PURPOSE OF REVIEW

The purpose of this review is to address our current understanding of the pathophysiology of neurologic injury resulting from severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection on the developing nervous system.

RECENT FINDINGS

SARS-CoV2 may enter the brain through three potential mechanisms: transsynaptic spread from the olfactory bulb following intranasal exposure, migration across the blood-brain barrier through endothelial cell infection, and migration following disruption of the blood-brain barrier from resulting inflammation. SARS-CoV2 does not appear to directly infect neurons but rather may produce an inflammatory cascade that results in neuronal injury. Additionally, autoantibodies targeting neuronal tissue resulting from the immune response to SARS-CoV2 are present in select patients and may contribute to central nervous system (CNS) injury.

SUMMARY

These findings suggest that neuronal injury during SARS-CoV2 infection is immune mediated rather than through direct viral invasion. Further multimodal studies evaluating the pathophysiology of neurologic conditions in pediatric patients specifically following SARS-CoV2 infection are needed to improve our understanding of mechanisms driving neurologic injury and to identify potential treatment options.

Vertical Transmission of SARS-CoV-2: A Systematic Review of Systematic Reviews

The COVID-19 pandemic has hugely impacted global public health and economy. The COVID-19 has also shown potential impacts on maternal perinatal and neonatal outcomes. This systematic review aimed to summarize the evidence from existing systematic reviews about the effects of SARS-CoV-2 infections on maternal perinatal and neonatal outcomes. We searched PubMed, MEDLINE, Embase, and Web of Science in accordance with PRISMA guidelines, from 1 December 2019 to 7 July 2021, for published review studies that included case reports, primary studies, clinical practice guidelines, overviews, case-control studies, and observational studies. Systematic reviews that reported the plausibility of mother-to-child transmission of COVID-19 (also known as vertical transmission), maternal perinatal and neonatal outcomes, and review studies that addressed the effect of SARS-CoV-2 infection during pregnancy were also included. We identified 947 citations, of which 69 studies were included for further analysis. Most (>70%) of the mother-to-child infection was likely due to environmental exposure, although a significant proportion (about 20%) was attributable to potential vertical transmission of SARS-CoV-2. Further results of the review indicated that the mode of delivery of pregnant women infected with SARS-CoV-2 could not increase or decrease the risk of infection for the newborns (outcomes), thereby emphasizing the significance of breastfeeding. The issue of maternal perinatal and neonatal outcomes with SARS-CoV-2 infection continues to worsen during the ongoing COVID-19 pandemic, increasing maternal and neonatal mortality, stillbirth, ruptured ectopic pregnancies, and maternal depression. Based on this study, we observed increasing rates of cesarean delivery from mothers with SARS-CoV-2 infection. We also found that SARS-CoV-2 could be potentially transmitted vertically during the gestation period. However, more data are needed to further investigate and follow-up, especially with reports of newborns infected with SARS-CoV-2, in order to examine a possible long-term adverse effect.